Pregnancy Form

Name*

Address*

Phone*

Email Address*

Birthdate*

Emergency Contact Name & Number*

OBGYN/Midwife Name, Clinic Name & Phone Number *

Referred By

Age*

Week of Pregnancy *

Due Date *

Are you a high risk pregnancy? *

Yes

If yes, please have physician note authorizing therapeutic massage

Are you expecting*

One Baby

Multiples

Please check any complications or conditions related to this pregnancy *

Waiver of Liability and Consent to have Massage*

I agree to submitting intake forms online and waive all claims.

I agree to hold harmless Relax & Be Well, LLC, of all claims, including Andree Strauss, her spouse, her heirs, her property and associations.

I understand that my information will not be shared with anyone outside of Relax & Be Well, LLC without my written consent.

I understand that I need a physicians approval for therapeutic massage if I am a high risk pregnancy.

I understand that the massage therapist cannot diagnose any medical conditions, but they can recommend seeing a medical doctor or medical specialist with any concerns.

I understand that if I choose to have a cupping session (alone or added to massage) that there may be visible marks left on my body, that may last up to a couple of weeks and that cupping is contraindicated on the abdomen, lower back and ankles during pregnancy.

I have answered the above information to the best of my knowledge and will let the practitioner know if anything changes with my health history.

Cancellation Policy*

I understand that I will be charged 50% of my scheduled service fee if I cancel my appointment less than 24 hours before my scheduled time, with the exception of illness, emergency or inclement weather.

I understand I will NOT be charged if I need to cancel within 24 hours due to COVID-19 symptoms in myself or another member of my household.